Why don't we take a look at the patient? : an anthropological analysis of how doctors become doctors

Abstract

The present thesis is a study of how doctors learn to make clinical decisions; decisions about diagnosis and therapy of the individual patient in the context of the clinic. It is based on ethnographic fieldwork and anthropological analysis carried out in 2006-2009. The key informants are nine doctors who go through internship and the empirical field is the wards and clinics of regional hospitals, university hospitals and general practice.<br> The thesis is in three parts. The first part is the design of the study. This includes reviews of clinical reasoning (Chapter 1) and medical education (Chapter 2); the conceptualization of clinical decision-making (Chapters 3-4) and the development of a theoretical framework of learning (Chapter 5); a presentation of ethnographic fieldwork as methodological approach with special considerations of auto-ethnography (Chapters 6-7); and a description of the process of analysis (Chapter 8).<br> The second part is the findings of the study. This is made up by four chapters, which each describe one of four processes of construction in decision-making and how the interns learn to participate in these constructions. Each of these chapters is followed by a chapter, which discuss conditions of clinical work that facilitate this learning. Chapter 9 describes the construction of relations, and Chapter 10 discusses the dynamics of clinical space as the context for these relations. Chapter 11 describes the construction of decisions, and Chapter 12 discusses the relation between these decisions and the norms and ideals for clinical reasoning, including evidence-based medicine. Chapter 13 describes the construction of information, and Chapter 14 discusses the clinical language which interns must learn to use in communication. Chapter 15 describes the construction of action, and Chapter 16 discusses the moral aspects of clinical practice and how the local moral economy guide clinical practice.<br> The interns are found to learn the practice of participating in complex interactional processes of decision making. Through this process they develop an identity as professional. They learn to adapt to local conditions for clinical work. They learn to search for problems which are simple and acute, to solve these through technical rapid action, and to express their reasoning through a specialized clinical language in line with local spectrums of normality. This is described as the <i>per astra </i> pathway.<br> In this extensive learning process, they come to embody the norms and traditions of the various clinical settings. This makes them effective in clinical practice, but also generates a special blindness in the clinical gaze. When uncertainty or wonder arise in clinical encounters, they have little experience in deliberate reflection and creative interaction, and they learn instead to revert to the general decision pathway above.<br> Parallel to this empirical track of the project is a search for, and development of, a theoretical perspective able to describe clinical decision-making in practice. This is presented in the third part of the thesis and discussed in relation to the empirical findings. Chapter 17 presents the synthesis of the theoretical track of the project in <i>the Prometheus perspective</i> and <i>the Clinic Action CycIe.</i> Chapter 18 explores how same of the interns’ actions may be reinterpreted as a potential for learning in the light of the new perspective. Chapter 19 suggests how it may serve as a framework for discussion and development of decision-making in the context of medical education and clinical practice. The new perspective differs from established conceptualizations of clinical reasoning, and epistemological groundwork and continued research of clinical practice is needed to unfold the potential of this new perspective. Chapter 20 presents an integrated summary of the empirical and the theoretical track of the project.